PROTOCOL: Social interventions to improve well‐being of people with mental disorders: Global evidence and gap map

Abstract Introduction: Mental illnesses play a role in poor health outcomes. Mental health is just as vital as physical health for an individual's total well‐being. Alterations in mental health can have a significant impact on all aspects of life, including school or work performance, relationships with family and friends, and community participation. As a result, we would like to provide an overview of psychosocial interventions that are available to improve the well‐being of people with mental health conditions and map available studies on the effectiveness of interventions provided in framework. Methods: This Evidence Gap Map will feature systematic reviews of the effects of interventions and effectiveness studies that used either: (a) randomised experimental design, or (b) rigorous quasi‐experimental design, (c) natural experiments, (d) regression discontinuity, (e) propensity score matching, (f) difference in difference, (g) instrumental variables, (h) and other matching design, (I) Single subject design. We will include qualitative studies, relevant working papers will also be included. Also, language restricted to english from any country will be reviewed for inclusion. Electronic Search will be conducted with the help of a relevant databases in our area of study. Outcomes: Will be focused mainly on the basis of community‐based Rehabilitation matrix adapted from the comprehensive mental health action plan, 2013‐2020.

Currently, about 450 million people worldwide have experienced any one/several kind of mental health conditions and behavioural disorders. One in four individuals developed one or more of these mental health conditions during their lifetime (WHO-Effective interventions and policy options, 2019a).
Between 76% and 85% of people with severe mental health conditions receive no treatment in LMICs; the corresponding range for high income countries (HICs) is also high: between 35% and 50%.
Neuropsychiatric conditions account for 13% of the total Disability Adjusted Life Years (DALYs) lost due to all diseases and injuries in the world and are estimated to increase to 15% by the year 2020. DALYs for a disease are the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the health condition. The DALY is a health gap measure that extends the concept of potential years of life lost due to premature death (PYLL) to include equivalent years of "healthy" life lost in states of less than full health, broadly termed disability.
Five of the 10 leading causes of disability and premature death worldwide are due to mental ill-health. Mental illness not only represent an immense psychological, social and economic burden to society, but also increase the risk of physical illnesses (WHO, 2004).

| Global evidence
Global target from WHO advert 80% of countries will have developed or updated their policies/plans for mental health in line with international and regional human rights instruments by the year 2020 (SDG-Mental-healthupdate-2018, WHO, 2018. The disability caused by mental and neurological disorders is high in all regions of the world. As a proportion of the total, however, it is comparatively less in the developing countries, mainly because of the large burden of communicable, maternal, perinatal and nutritional conditions in those regions. Even so, neuropsychiatric disorders cause 17.6% of all YLDs in Africa (Leonardi, 2003).
Taken together, mental, neurological and substance use disorders exact a high toll, accounting for 13% of the total global burden of disease in the year 2004. Depression alone accounts for 4.3% of the global burden of disease and is among the largest single causes of disability worldwide (11% of all years lived with disability globally), particularly for women. The economic consequences of these health losses are equally large: a recent study estimated that the cumulative global impact of mental disorders in terms of lost economic output will amount to US$ 16.3 million between 2011 and 2030 (Comprehensive mental health action plan report, 2013-2020, WHO, 2013).

| Comprehensive mental health action plan 2020, WHO
The vision of the action plan is a world in which mental health is valued, promoted and protected, mental disorders are prevented and persons affected by these disorders are able to exercise the full range of human rights and to access high quality, culturally appropriate health and social care in a timely way to promote recovery, all to attain the highest possible level of health and participate fully in society and at work free from stigmatisation and discrimination. Its overall goal is to promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability for persons with mental disorders.
The action plan has the following objectives: (1) To strengthen effective leadership and governance for mental health; (2) To provide comprehensive, integrated and responsive mental health and social care services in community-based settings; (3) To implement strategies for promotion and prevention in mental health; (4) To strengthen information systems, evidence and research for mental health.
The global targets established for each objective provide the basis for measurable collective action and achievement by Member States towards global goals and should not negate the setting of more ambitious national targets, particularly for those countries that have already reached global ones.
The action plan relies on six cross-cutting principles and approaches: but important one for us being the "Evidence-based practice" that concentrates on mental health strategies and interventions for treatment, prevention and promotion that needs to be based on scientific evidence and/or best practices, taking cultural considerations also into account.

| Mental health interventions
The WHO Department's work on mental health in emergencies focuses mostly on resource-poor countries, where most populations exposed to natural disasters and war live.
Some of the interventions have successfully been implemented by community health workers in low-income countries as part of research programmes that ensured that community health workers had the time to learn and implement these interventions under supervision.
The interventions described below cover both psychological and social interventions (broader categories) that will be included to map in this review.  Although the content should be culturally sensitive, it should not allow violation of children's basic human rights according to internationally endorsed principles. Providing parent training requires that the health-care providers receive training themselves.
6. Problem-solving counselling or therapy: A psychological treatment involving offering direct and practical support. The therapist and person work together to identify and isolate key problem areas that might be contributing to the person's mental health problems, to break these down into specific, manageable tasks, and to problem-solve and develop coping strategies for particular problems. The mhGAP-IG recommends it as an adjunct treatment option for depression (including bipolar depression) and as a treatment option for alcohol use disorders or drug use disorders. It is also recommended for self-harm, other significant emotional or medically unexplained complaints, or parents of children and adolescents with behavioural disorders. 7. Relaxation training: This intervention involves training the person in techniques such as breathing exercises and progressive relaxation to elicit the relaxation response. Progressive relaxation teaches how to identify and relax specific muscle groups. Usually treatment consists of daily relaxation exercises for at least 1-2 months. The mhGAPIG recommends it as an adjunct treatment option for depression (including bipolar depression), and as a treatment option for other significant emotional or medically unexplained complaints.

Social skills therapy
Social skills therapy helps rebuild skills and coping in social situations to reduce distress in everyday life. It uses role-playing, social tasks, encouragement and positive social reinforcement to help improve ability in communication and social interactions.

Skills training can be done with individuals, families and groups.
Usually treatment consists of 45-90 min sessions once or twice per week for an initial 3 months and then every month. The mhGAP-IG recommends it as a treatment option for people with psychosis or behavioural disorder.
A new WHO self-help approach for managing distress and coping with adversity has shown to be safe and effective in a trial involving South Sudanese women living in Uganda. The results of the study indicate that guided self-help could be a promising strategy to address the vast gap in mental health support in humanitarian response situations (Brown et al., 2018).
Hence, sound mental health is related to mental and psychological well-being. WHO's work to improve the mental health of individuals and society at large includes the promotion of mental health well-being, prevention of mental disorders, protection of human rights and caring for people affected with mental health conditions.

| Key to obtain sound mental health
The only sustainable method for reducing the mental health burden is through prevention of mental illness and promotion of mental health.
Mental health is fundamental to good health and well-being and influences social and economic outcomes across the lifespan (Barry & Friedli, 2008;Durlak & Wells, 1997;Jenkins et al., 2011). This is possible with understanding of effective mental health and social interventions available and to enhance further research in the areas undone to raise the quality of community health services reaching the population.
Systematic reviews (SRs) of the international evidence, which come predominantly from HICs, show that comprehensive mental health promotion interventions carried out in collaboration with families, schools and communities, lead to improvements not only in mental health but also improved social functioning, academic and work performance, and general health behaviours (Barry et

| Why it is important to do this review
There is an ongoing Campbell EGM on disability in LMICs. Also, there is an existing map on acupuncture for mental health by Department of Veteran Affairs. However, the former map focuses only on LMICs and the later focusses on specific interventions only. There are few SRs available on effectiveness of interventions for the promotion of mental health among the young people in LMICS (Barry et al. 2013;Das et al. 2016).

| OBJECTIVES
The specific objectives of this map are to:   economies for the fiscal year, which is based on the Atlas gross national income per capita estimates (Annex: 1 and 2).

Governance and leadership
Governance in the health sector refers to a wide range of steering and rule-making related functions carried out by governments/decisions makers as they seek to achieve national health policy objectives that are conducive to universal health coverage. Governance is a political process that involves balancing competing influences and demands. A strong civil leadership in the community and organisations for people experiencing mental health conditions and psychosocial disabilities can be of great help to enforce effective and accountable policies, laws and services in a manner consistent with international as well as regional human rights associations including their caregivers and close family members as well. • Active surveillance systems Good-quality mental health service systems that are available including social interventions for mentally disordered people and the interventions/initiatives from health workers in improving wellbeing of people with mental disorders and vice versa, because of the high rates of co-morbid mental health problems.

| Community based-mental health services
Community-based service delivery for mental health needs to encompass a recovery-based approach that puts the emphasis on supporting individuals with mental disorders and psychosocial disabilities to achieve their own aspirations and goals. A multi sectoral approach in providing supportive services to the individuals, at different stages of the life course and, as appropriate, facilitate their access to human rights such as employment (including return-to-work programmes), housing and educational opportunities, and participation in community activities, programmes and meaningful activities.
• Human resource development

• Facility-based interventions
Interventions like improving physical activities and counselling or other various facilities available precisely for the people with mental disorders will be mapped.

| Mental health Promotion
WHO defines health promotion as "the process of enabling people to increase control over, and to improve their health" (WHO, 2004).
Mental health promotion often refers to positive mental health, rather DSOUZA ET AL.

| Types of outcome measures
Primary outcome measures are detailed below

Primary outcomes
A community-based rehabilitation (CBR) programme is formed by one or more activities in one or more of the five components (health, education, livelihood, social and empowerment) (Khasnabis et al., 2010). A part of CBR matrix for the social outcomes has been modified with the addition of Quality of Life as an outcome that has been adapted from the World Health Organisation's comprehensive mental health action plan (2013-2020).
Health • Physical health

| Search methods for identification of studies
Studies in English language and from any country will be reviewed for inclusion.
Electronic Search will be conducted with the help of a relevant databases in our area of study. Key words with synonyms will be used for the specific search to be conducted. It is planned to search the following databases/search engines (Refer to Annex: 2).

| Data collection and analysis
There will be four independent reviewers working in this EGM on EPPI reviewer 4. Each one of them will be responsible to carry out the search and screening. Independent title and abstract screening will be done and the selected studies will be included for the next stage of full text review after discussion with the team members. In case of any doubts, consensus from the third person will be taken and then decided on exclusion of the paper. The final consensus will be taken with the subject experts. The latter will follow the same for full text screening.

| Selection of studies
Title and abstracts will be reviewed initially by four independent authors in Eppi reviewer-4 and any studies will be checked for duplication. Excluded studies will be reported after an expert suggestion. Following this, full text screening of selected studies from the title abstract and stage will be conducted in relation to the set inclusion/exclusion criteria's. If there is a considerable level of disagreement, the third reviewers will resolve the conflict. The study will be assessed for quality using AMSTAR-2 scale. Any potential differences in interpretation will be discussed and resolved by the expert team.

| Data extraction and management
We will code each included study using a piloted coding tool covering study characteristics, population, intervention and outcomes (ANNEX 3).

| Assessment of risk of bias in included studies
AMSTAR-2 for SRs and modified risk of bias for primary studies.

| Dealing with missing data
The lead author will be contacted for retrieval of the missing data. If the author would fail to respond back then we will exclude the article from the review reporting it as Missing data.
| 7 of 10 3.6.5 | Assessment of heterogeneity Not planned for now.

| Data synthesis
If it is possible to conduct a meta-analysis with the available data, Review Manager Software from the Cochrane Collaboration will be used to analyse the data. If statistical pooling is not possible the findings will be presented in narrative form. The data will be mapped as intervention and outcome tables.
3.6.7 | Subgroup analysis and investigation of heterogeneity Subgroup analysis will be conducted to assess the heterogeneity between the included studies.
3.6.8 | Sensitivity analysis Sensitivity analysis will be performed to assess the impact of methodological quality. Analysis will be conducted by excluding the included studies at high risk of bias for any one or more of selection, attrition, or detection bias. The Meta-analysis will be repeated after removing the lower quality studies.
3.6.9 | Summary of findings and assessment of the certainty of the evidence AMSTAR-2 will be used for assessment of SRs

ACKNOWLEDGEMENTS
We are grateful to members of the campbell disability coordinating team for their support throughout TRF phase of this study.

DECLARATIONS OF INTEREST
There is no conflict of interest.